Clinical Suspicion Of Celiac Disease Research Articles

Diagnostic Accuracy of Endoscopic Findings (Duodenal Fissuring) in Diagnosis of Celiac Disease

Objective: This study aims to determine the diagnostic accuracy of endoscopic findings, specifically duodenal fissuring, in the diagnosis of celiac disease, thus contributing to a more efficient and accurate diagnostic approach in clinical practice. Study Design: A descriptive cross-sectional study was employed to assess the diagnostic accuracy of endoscopic findings in the diagnosis of celiac disease. Setting: The study was conducted at the Endoscopy Suite, Section of Gastroenterology, Department of Medicine, Aga Khan University Hospital, Karachi. Duration: The research was carried out over six months, from 30-06-20 to 30-12-20, following the approval of the synopsis. Methods: A sample of 130 patients presenting with clinical suspicion of celiac disease was recruited for this study. Participants underwent upper gastrointestinal endoscopy, with duodenal biopsies obtained for histopathological analysis. The presence of duodenal fissuring was recorded, and the diagnostic accuracy of endoscopic findings was evaluated against histopathological results as the gold standard. Results: Our findings demonstrate a strong correlation between the presence of duodenal fissuring and the diagnosis of celiac disease. The endoscopic findings revealed a sensitivity of 80.0%, specificity of 92.3%, positive predictive value of 88.9%, negative predictive value of 85.3%, and an overall diagnostic accuracy of 85.4% for celiac disease. Conclusion: The study concludes that endoscopic findings, particularly duodenal fissuring, offer a high diagnostic accuracy in the identification of celiac disease. Incorporating these findings into the diagnostic algorithm can significantly enhance clinical decision-making and contribute to a more efficient and accurate diagnosis of celiac disease. Keywords: celiac disease, diagnostic accuracy, endoscopic findings, duodenal fissuring, upper gastrointestinal endoscopy, histopathology, sensitivity, specificity

The correct methodological approach to the diagnosis of celiac disease: the point of view of the pathologist.

The diagnosis of celiac disease relies on the assessment of serological data and the presence of histological alterations in the duodenal mucosa. The duodenal biopsy is pivotal in adults, and in some circumstances in children, to confirm the clinical suspicion of celiac disease. The correct interpretation of duodenal biopsies is influenced by numerous variables. The aim of this overview is to describe the correct methodological approach including the procedures of biopsy sampling, orientation, processing, staining and histopathological classification in order to avoid or minimize the errors and the variability in duodenal biopsy interpretation. Multiple biopsies taken from different sites of the duodenum during endoscopy maximize the diagnostic yield of duodenal histological sampling. Proper orientation of the biopsy samples is of the utmost importance to assess histological features of pathological duodenal mucosa and to avoid artifacts that may lead even an experienced pathologist to a wrong histological interpretation with subsequent misdiagnosis of celiac disease. An immunohistochemical stain for CD3 can be invaluable to aid the pathologist in obtaining a more accurate intra-epithelial T lymphocytes count. A simplified histological classification facilitates the clinician's work and improves the communication between pathologist and clinician. An integrated clinical and pathological approach is required for a correct diagnosis of celiac disease since a relatively large number of conditions may cause duodenal damage with a histological appearance similar to that of celiac disease.

Diagnostic Value of Immunoglobulin G Anti-Deamidated Gliadin Peptide Antibody for Diagnosis of Pediatric Celiac Disease: A Study from Shiraz, Iran.

PurposeScreening serologic tests are important tools for the diagnosis of celiac disease (CD). Immunoglobulin (Ig)G anti-deamidated gliadin peptide (anti-DGP) is a relatively new autoantibody thought to have good diagnostic accuracy, comparable to that of anti-tissue transglutaminase (anti-tTG) antibody.MethodsPediatric patients (n=86) with a clinical suspicion of CD were included. Duodenal biopsy, anti-tTG, and IgG anti-DGP antibody tests were performed. The patients were divided into CD and control groups based on the pathological evaluation of duodenal biopsies. The diagnostic accuracy of serological tests was determined.ResultsIgA anti-tTG and IgG anti-DGP antibodies were positive in 86.3% and 95.4% of patients, respectively. The sensitivity, specificity, and diagnostic accuracy of the IgA anti-tTG test were 86.3%, 50.0%, and 68.6%, respectively, and those of the IgG anti-DGP test were 95.4%, 85.7%, and 90.7%, respectively. The area under the receiver operating characteristic (ROC) curve was 0.84 (95% confidence interval [CI], 0.74–0.91) for IgA anti-tTG test and 0.93 (95% CI, 0.86–0.97) for IgG anti-DGP test. The comparison of IgA anti-tTG and IgG anti-DGP ROC curves showed a higher sensitivity and specificity of the IgG anti-DGP test.ConclusionIgG anti-DGP is a reliable serological test for CD diagnosis in children. High tTG and DGP titers in the serum are suggestive of severe duodenal atrophy. The combined use of IgA anti-tTG and IgG anti-DGP tests for the initial screening of CD can improve diagnostic sensitivity.

Morphological evaluation of bulb and distal duodenal biopsies in pediatric celiac disease with clinical and serological correlation.

An early correct diagnosis of celiac disease (CD) is fundamental to reversal of symptoms and prevention of complications in pediatric patients. Our aim was to evaluate the role of duodenal bulb biopsy by studying the degree of mucosal damage in the duodenal bulb (D1) and second part of the duodenum (D2) and correlating the findings with serum IgA anti-tTG levels. Pediatric patients (age <18 years) with clinical suspicion of CD and positive IgA anti-tTG titers were consecutively enrolled over a period of one year. Demographic variables, anthropometry, clinical history, laboratory values and endoscopic findings were studied. Endoscopic biopsies obtained from D1 and D2 were evaluated and assigned histopathologic grades that were correlated with serology. Descriptive statistics were employed. A total of 37 clinically suspected cases of pediatric CD were studied. The mean age was 6.7 years and the M:F ratio was 1:1.3. Thirty-two (32) children had varying degrees of growth impairment. Eight (8) children had only extra-intestinal symptoms. Thirty (30) children were anemic, hypoalbuminemia was seen in five (5) children while transaminitis was seen in two (2) children. IgA anti-tTG >300 U/ml was associated with Marsh-Oberhuber Grade 3 morphology at atleast one site. Low positive serology values should be confirmed by histopathology. Biopsies should be taken even in the absence of endoscopic abnormality. Additional D1 biopsies placed in a separate container can increase the diagnostic yield.

Image Case : Celiac Disease in 14 Years Old Girl with Type 1 Diabetes Mellitus

Celiac disease is an autoimmune disease that primarily affects the small intestine. Classic symptoms in children include gastrointestinal disorders as chronic diarrhea, malabsorption and failure to grow normally. It is associated with other autoimmune diseases, such as thyroiditis and diabetes mellitus type 1 . Mild or absent gastrointestinal symptoms may be found specially in older people.Celiac disease may be presented with rare but life threatening crisis. 14 years old underbuilt anemic (iron deficiency) girl with type 1 diabetes mellitus without gastrointestinal symptoms was endoscopicaly examined for clinical suspicion of Celiac disease. On endoscopic examination there was fissurization (cracked-mud ) of the mucosa of the duodenal bulb as well as descending duodenum. Pathological examination of the endosopic biopsies confirmed the diagnosis. Upper gastrointestinal endoscopy in celiac disease usually shows scalloped (indentations and erosions) blunted duodenal mucosa, visible mucosal vessels, micronodular appearance of the mucosa and mucosal fissures(cracked-mud). Duodenal biopsy shows villous blunting with intraepithelial lymphocytosis.

Serum intestinal fatty acid-binding protein in the noninvasive diagnosis of celiac disease.

Current diagnostic guidelines for celiac disease (CD) in pediatric patients require a duodenal biopsy if the IgA anti-tissue transglutaminase (tTG) is below 10x the upper limit of normal (ULN). Additional markers may enable a noninvasive diagnosis in this group. Serum intestinal-fatty acid-binding protein (I-FABP), a marker for intestinal epithelial damage, could be useful in this respect. A total of 95 children with a clinical suspicion of CD and tTG 1-10x ULN were investigated. All had a duodenal biopsy and analysis of serum I-FABP. A control group of 161 children with familial short stature and normal tTG was included. I-FABP levels in the 71 patients with tTG 1-10x ULN and biopsy-proven CD (median 725pg/mL) were not significantly different (p=0.13) from the levels in the 24 patients with a tTG 1-10x ULN but a normal biopsy (median 497pg/mL). However, when combining tTG and I-FABP levels, 11/24 patients could have been diagnosed noninvasively if tTG is ≥ 50 U/mL and I-FABP ≥880pg/mL or in 12/19 patients if tTG is ≥ 60 U/mL and I-FABP ≥ 620pg/mL. Therefore, addition of I-FABP to the diagnostic procedure of CD may provide a noninvasive diagnosis in patients with a tTG ≥ 50 U/mL.

Screening for coeliac disease in type 1 diabetes

In this issue of Acta Paediatrica, Laitinen et al. 1 explore symptoms and mucosal damage in 22 patients with type 1 diabetes who were screened for coeliac disease and compared them to 498 individuals diagnosed with coeliac disease on a clinical basis. The authors concluded that screening for coeliac disease should be considered among children with type 1 diabetes, which is in line with current recommendations 2-4. A meta-analysis found that coeliac disease occurred in more than one in 20 patients with type 1 diabetes 5, and long-term coeliac disease may influence the risk of both retinopathy and chronic renal disease in type 1 diabetes 6, 7, potentially due to an increased prevalence of microvascular complications in patients with both type 1 diabetes and coeliac disease 8. The paper by Laitinen et al. 1 is interesting for several reasons. First of all, the authors found that patients with type 1 diabetes and coeliac disease did differ from patients diagnosed with coeliac disease due to clinical symptoms. For instance, patients with type 1 diabetes and coeliac disease did not experience such poor growth as those with clinically diagnosed coeliac disease. That is reassuring, as poor growth in childhood can have long-term consequences. Although catch-up growth is commonly seen in children with coeliac disease just after diagnosis, restricting food intake to make a diet suitable for both type 1 diabetes and coeliac disease could theoretically make catch-up growth more difficult to achieve. The authors also found that while children with type 1 diabetes and coeliac disease often had unrecognised gluten-dependent symptoms, these were less severe than in children who were clinically diagnosed with coeliac disease. That was to be expected, because otherwise the children with type 1 diabetes and coeliac disease should have been diagnosed before, due to gastrointestinal symptoms, rather than just after their diagnosis of type 1 diabetes. We believe that the lower prevalence of symptoms reflects the fact that patients with type 1 diabetes and coeliac disease may have less severe small-bowel mucosal atrophy than patients who just have coeliac disease. We disagree with Laitinen et al. on their interpretation in this regard, as we believe that the lack of difference with regard to mucosal atrophy in their study was due to lack of power. Laitinen et al. based their findings on only 22 patients with type 1 diabetes and coeliac disease and the statistical lack of difference was probably due to the equal proportions of patients with subtotal villous atrophy. Estimating total villous atrophy from their Figure 1B seems to indicate that it was more common in patients with clinical suspicion of coeliac disease (roughly 23% versus 9%), while partial villous atrophy was more common in patients with type 1 diabetes (52% versus roughly 32%). The same objection could be raised about the conclusion that dietary adherence was similar in patients with both type 1 diabetes and coeliac disease and those with just coeliac disease. The power for dietary adherence was limited in type 1 diabetes and coeliac disease patients as there was only dietary data for 16 of the 22 patients, and the p value of 0.086 may have reached statistical significance if the type 1 diabetes and coeliac disease group had been larger. This said, it should be emphasised that a very high proportion of patients with type 1 diabetes and coeliac disease did comply with the diet. Nevertheless, the long-term implications of prescribing a life-long diet for a child based on screening are unknown, as adherence to a gluten-free diet may decline in adolescence among children with screen-detected coeliac disease. While the strongest evidence for the value of screening for coeliac disease would be derived from a randomised trial, in which a nonscreened group would be compared to a screened group with regard to morbidity, the length and expense of such a trial would probably be prohibitive. As such, we rely on observational studies, such as those by Laitinen et al., to inform us of the potential outcomes of screening. In conclusion, this article makes a valuable contribution to the literature and once again underlines the potential value of examining children with type 1 diabetes for other autoimmunity problems, including coeliac disease. None. None.

Celiac disease: Confounding presentations of Jeopardy in Indians

Background: Celiac disease (CD) (also called gluten-sensitive enteropathy and nontropical sprue) is a known entity since 1888, is a common immune-mediated enteropathy due to allergy to gluten, with a prevalence of approximately 1% worldwide. It has wide spectrum of manifestations ranging from failure to thrive, gastrointestinal symptoms to various autoimmune diseases and malignancies. Materials and Methods: The clinical profile of patients diagnosed as CD, presenting at tertiary care hospital of armed forces, was evaluated. The patients were diagnosed as CD as per ESPGHAN guidelines on the basis of symptoms, positive serology, and histological findings (duodenal biopsy). After history and clinical suspicion of CD, IgA anti-tissue transglutaminase antibody was done. Complete history, physical examination, and baseline investigations including complete blood counts, serum glucose, thyroid function tests, etc., were recorded. Results: The average age of the cohort was 21.03 years (range 3–75 years). The most common presentation was diarrhea (80.7%) followed by anemia (63.2%) and weight loss (56%). Anemia was found to be second most common presentation after diarrhea and was seen in 63.2%. The prevalence of autoimmune conditions, namely, type-1 diabetes mellitus and thyroiditis were seen in two cases (3.5% each). Conclusion: CD is a common immune-mediated condition though typically presenting with gastrointestinal symptoms, atypical manifestations are also not uncommon. Suspicion of this condition and the appropriate investigations should not be delayed in patients presenting with either typical manifestations or uncommon presentations.

The Usefulness of IgA/IgG DGP/tTG Screen Assay for Celiac Disease Detection among Symptomatic and at Risk Young Children

Background: It has been postulated that IgA anti tissue-transglutaminase (tTG) and anti-endomisium (EMA) antibodies can be false negative in young children.ESPGHAN recommended for seronegative children younger than 2 years old with clinical suspicion of celiac disease to perform duodenal biopsies. Recent studies sugested that the combined assay for IgA/IgG deamidated gliadin peptides (DGP) and tTG can detect celiac disease among seronegative young children. Aim: To assess if the new combined assay with synthetic gliadin derived peptides IgA/IgG-DGP/tTG is useful to detect celiac disease in IgA tTG or EMA seronegative children younger than 2 years old. Methods: The authors screened a lot of children aged 6 months to 2 years old that associated characteristic symptoms/risk factors for gluten enteropathy. 368 children were tested for IgAtTG, EMA and IgA/IgG-tTG/DGP combined assay. All children had normal total IgA concentration and were consuming gluten at the time of enrolment. Children with at least one positive serologic test underwent intestinal biopsy, including seronegative infants, DQ2/DQ8 positive, with clinical suspicion of celiac disease that underwent the 2 biopsies protocol. Results: Celiac disease was diagnosed in 22 children based on histology. 19 children were positive for IgA tTG, 20 were positive for EMA and 21 tested positive for IgA/IgG-DGP/tTG. IgA tTG sensitivity was 86.3%, IgA EMA sensitivity was 91% and IgA/IgG-DGP/tTG sensitivity was 95.4% (p=0.002). Conclusions: The sensitivity of IgA/IgG DGP/tTG assay was significantly higher than that of IgAtTG in celiac patients younger than 2 years old.The better performance of this new combined test can avoid repeated intestinal biopsies in young children with high clinical suspicion of celiac disease but negative tTG/ EMA serology.

Endoscopic evaluation of celiac disease.

Although serology-based diagnosis of celiac disease (CD) in children recently has been legitimized 1, small bowel biopsy remains the gold standard for diagnosis of the condition 2 3. Upper endoscopy, therefore, takes on paramount importance in management of CD for several reasons, including serendipitous discovery of endoscopic markers of CD, assessment of “patchy” villous atrophy, targeting of biopsy sampling, and evaluation of CD-related complications. Macroscopic markers of CD, estimable with white light endoscopy, include the “scalloped” appearance of duodenal folds, nodular pattern of the mucosa (the so-called “mosaicism”), evidence of submucosal vessels, and epithelial fissurations 4. The diagnostic accuracy of these findings is largely variable, according to different reports 5 6, and they are associated with a significant rate of underdiagnosis of CD 7 8. Because standard endoscopy is unreliable, other endoscopic tools have been investigated for diagnosis opf CD, which fall into two categories based on their working principle: machine-independent techniques and machine-dependent techniques; the latter include software- and hardware-dependent techniques 9 10. The water-immersion technique (WIT) and dye-staining chromoendoscopy and machine-independent. Software-dependent techniques include Narrow-Band Imaging (optical dye-less chromoendoscopy), Fujinon Intelligent Chromo Endoscopy (virtual dye-less chromoendoscopy) and i-SCAN, which are dyeless chromoendoscopy tools. Hardware-dependent techniques such as optical coherence tomography, confocal laser endomicroscopy, video capsule endoscopy, and enteroscopy can be performed only with dedicated tools that are different from regular gastroscopes, or with the use of probes 9 10. The combination of these techniques has been suggested to improve the detection of duodenal villous abnormalities 11. In this issue of Endoscopy International Open, Iacucci et al 12 present a retrospective cohort study of 58 patients with clinical suspicion of CD and positive serology testings who underwent upper endoscopy and duodenal evaluation with both white light endoscopy (WLE) and a combination of i-SCAN and WIT (iSCAN-HDWI). The duodenal view was respectively classified as normal, reduction of folds, mosaic pattern, scalloping and atrophy with visible vessels with WLE, and as normal, mild, moderate, patchy or severe villous atrophy with iSCAN-HDWI. The authors found a significant correlation between the endoscopic grade evaluated by iSCAN-HDWI and the histology score. Assessment with WLE showed a lower but significant grade of correlation. In particular, iSCAN-HDWI achieved 96 % sensitivity, 63 % specificity, and 100 % accuracy for predicting duodenal damage (excluding Marsh I lesions), whereas WLE showed 78 % sensitivity, 50 % specificity, and 72 % accuracy for the same gold standard. Respectively, WLE identified no abnormalities in 55.6 % of patients diagnosed with patchy villous atrophy and in 33.3 % of patients diagnosed with mild villous atrophy after iSCAN-HDWI evaluation. WIT is an easy technique that allows real-time enhancement of duodenal villous pattern during upper endoscopy. After aspiration of air from the duodenal lumen, the operator injects 100 mL to 150 mL of water to highlight villi 13. WIT achieved high levels of accuracy in diagnosing total villous atrophy (TVA), with only slightly less accurate results in identifying partial villous atrophy (PVA) 14 15 16 17. i-SCAN is a digital tool developed by Pentax Medical. It enhances images through three different modalities: contrast enhancement, which highlights mucosal abnormalities, particularly those of depressed areas; surface enhancement, which increases contrast between light and dark; and tone enhancement, which groups and recombines blue, red, and green components of images. i-SCAN produced results similar to WIT in assessment of TVA and PVA 18. The combination of iSCAN technology with WIT both highlights vascular and mucosal pattern and allows direct visualization of villi. Such a “joint-venture” can be of help in evaluating the duodenal villous pattern, especially in the case of partial or patchy villous atrophy, and in targeting biopsy sampling; therefore, it is advocated to decrease the number of CD misdiagnoses and related unnecessary costs. Further studies, combining other modalities for imaging enhancement, are therefore welcome to improve our knowledge of the diagnostic potential of endoscopic tools in CD.

Esophageal eosinophilia in pediatric patients with celiac disease: is it a causal or an incidental association?

Celiac disease (CD) and eosinophilic esophagitis (EoE) are 2 distinct disease entities affecting the gastrointestinal tract of pediatric patients. Recently it has been suggested that EoE is more prevalent in patients with celiac disease than in the general population. We studied the association between these 2 disease entities in our pediatric patients. We reviewed our hospital files for suspected or confirmed cases of CD. Only cases with both duodenal and esophageal biopsies in pediatric patients were included. A total of 120 patients who met these criteria were included as the disease group. We also selected 100 patients with no clinical suspicion of CD and included them as a control group. Slides were reviewed using established criteria for diagnosis of both conditions. Duodenal biopsies were categorized as positive, negative, and suspicious for CD, whereas esophageal biopsies were classified as either positive or negative for esophageal eosinophilia (EE). Serologic and clinical data were additionally collected. Sixty-two (62) cases were considered positive for CD in the disease group; among those 4 (6.5%) showed EE. In the control group, 91 cases were negative for CD, histologically, and 7 of those had EE (7.7%). Although 6 patients in the control group were histologically suspicious for CD, none of them had evidence of EE. Our findings show that, in our patient population, patients with CD are not more likely to have EE than patients undergoing upper endoscopy for other reasons. Therefore, we suggest that the association between CD and EE is likely incidental and not causal.

PTU-018 Can Chromoendoscopy help in Coeliac Disease as Part of a Duodenal Biopsy Strategy?

IntroductionChromoendoscopy is increasingly being used to detect, localise and characterise mucosal abnormalities, however its role in coeliac disease remains to be established. Endoscopic markers of coeliac disease (reduction of folds,...

71 Push Enteroscopy Leads to a Change in Diagnosis in the Majority of Patients With Positive Celiac Serology and Negative Duodenal Biopsy

Introduction Coeliac disease is associated with significant morbidity, and is an underdiagnosed condition with an estimated prevalence of 1% in the UK population. Current British Society of Gastroenterology Society guidelines classify individuals with positive coeliac serology and negative duodenal biopsy to latent coeliac disease and do not recommend further investigation or the initiation of a gluten free diet. In our recent practise patients at our institution with a strong clinical suspicion of coeliac disease and negative duodenal biopsies following a gluten containing diet undergo a push enteroscopy with biopsies of the jejunum and duodenum and histological reassessment of the original duodenal biopsies before a diagnosis of latent coeliac disease is made. We aimed to investigate whether push enteroscopy and histological reassessment increased the diagnostic yield of coeliac disease. Methods We searched our prospective endoscopy database for all patients with positive EMA or TTG results but negative D2 biopsies, who had undergone enteroscopy for a possible diagnosis of coeliac disease since 2007. Data including serology, result of histological reassessment of duodenal biopsies and assessment of jejunal biopsies were recorded. Results 13 patients were identified; 4 (31%) were male, the median age was 45 (range 19–78). In all 13, EMA testing had been performed, of which 9 were positive (69%). In 9, TTG results were available, of which 9 were positive (100%). Following review of the original duodenal biopsies by a second pathologist, 7 (54%) of the 13 patients were re-classified to active coeliac disease; median Marsh grade of 1 (range 0–2) Of the remaining 6 patients, 5 (83%) had evidence of active coeliac disease on jejunal biopsy; median Marsh grade of 2 (range 0–3b). Review of the jejunal biopsies alone, without review of original duodenal biopsies, would have led to active coeliac disease being diagnosed in 12 (92%) of 13 patients. Conclusion In this small retrospective series of patients with positive coeliac serology and negative duodenal biopsies, repeat histological assessment and jejunal biopsy led to a change in diagnosis in 92% of patients. These findings are unlikely to be limited to our institution. Our findings support the recommendation that a diagnosis of latent coeliac disease should only be made following repeat histological assessment and enteroscopy with jejunal biopsy. Disclosure of Interest None Declared.

Evaluation of a point-of-care test based on deamidated gliadin peptides for celiac disease screening in a large pediatric population

Celiac disease (CD) is nowadays known to be a common chronic enteropathy that is becoming a growing public health concern. Yet, it is estimated that more than 90% of patients remain undiagnosed. A point-of-care diagnostic test can be a rapid and cost-effective solution in the first-line screening of CD. The aim of this study is to evaluate the performance of a novel point-of-care screening test in a large pediatric population. Serum samples were collected from a cohort of 250 children presenting either an increased risk or a clinical suspicion of CD. All sera were tested using the point-of-care test detecting IgA and IgG antibodies against a combination of three different deamidated gliadin peptides as well as total IgA. The results of the screening test were compared with an enzyme-linked tissue transglutaminase immunosorbent assay and with histology resulting from intestinal biopsies performed in patients with elevated titers of antitissue transglutaminase antibodies. The point-of-care test showed highly concordant results with the laboratory immunoassay, yielding a sensitivity of 93.1 (78-98.1%) and a specificity of 95% (91.2-97.2%), with a diagnostic accuracy of 94.8% (91.3-96.9%) and a negative predictive value of 99.1% (96.6-99.7%). The screening test identified all patients with celiac-type histology findings on biopsy, as well as all patients with concomitant IgA deficiency. With a high diagnostic accuracy, this novel point-of-care approach is an efficient tool for CD case finding in pediatric populations. It has the potential to improve the management of celiac patients in primary care by providing faster counseling and treatment.

724 Hla Dq2/Dq8 Typing in Children Diagnosed with Celiac Disease

Background and AimsGenes encoding HLA DQ2/DQ8 are associated with celiac disease (CD) and testing for their presence has high negative predictive value for the diagnosis. The aim of this study...

PWE-185 The diagnostic yield of duodenal biopsy in coeliac disease relative to clinical indications and serology findings: an analysis of 2109 patients

IntroductionSerology testing with IgA tissue transglutaminase (TTG) is relatively cheap and non-invasive which NICE guidelines for coeliac disease (CD) advocate as a first choice test for patients with unexpected weight...

In Adults Referred with Non-specific Abdominal Symptoms, Lower BMI (Body Mass Index) is Associated with Celiac Disease

Purpose: To evaluate whether BMI could help identify patients with celiac disease, amongst those referred with symptoms suggestive of celiac disease, such as abdominal pain, bloating and diarrhea; and to thereby identify a subset of patients likely to require duodenal biopsies during upper endoscopy. Methods: We measured the BMI of 229 patients with a clinical suspicion of celiac disease undergoing upper endoscopy. Duodenal biopsies were obtained on all patients. The diagnosis of celiac disease was made in 14 patients on the basis of characteristic histology. Of the remaining 215 patients with normal histology, 115 followed up as did all 14 patients with celiac disease. All patients were followed for an minimum of 6 months. All celiac patients improved on a gluten-free diet. Results: In patients with celiac disease, the mean BMI was 24.9 kg/m2, median 24 (n=14) with confidence limits of +/−1.8. In patients without celiac disease, the mean BMI was 28.8, median 28 (n=115) with confidence limits of +/−1.3. The difference was statistically significant (p<0.001). Conclusion: The clinical presentation of celiac disease is often non-specific. The gold standard for diagnosis remains small bowel biopsy. The results indicate that a lower BMI may help to distinguish patients with celiac disease. In the current environment, the expense of small bowel biopsies on all patients with non-specific symptoms may be challenged. The BMI may afford gastroenterologists a clinical tool to evaluate the pre-test probability of celiac disease and thereby decide whether or not to biopsy the small bowel.

Suboptimal Performance of IgG Anti-tissue Transglutaminase in the Diagnosis of Celiac Disease in a Tropical Country

Serological tests using human IgA-anti-tTG have been reported to have high sensitivity and specificity in diagnosis of celiac disease. There is a paucity of data on the use of human IgG-anti-tTG in diagnosis of celiac disease. Ninety-two patients with clinical suspicion of celiac disease who underwent duodenal mucosal biopsy and celiac serology using human IgG-anti-tTG were included in this retrospective study. Diagnostic accuracy of human recombinant IgG-anti-tTG serological test for celiac disease was evaluated. Indications for celiac serological testing were diarrhea (92.3%), hypoalbuminemia (39.1%), and anemia (35.9%). Eighteen patients were diagnosed with having celiac disease and 14 (77.8%) of them were IgG-anti-tTG positive. Of the remaining 74 patients, eight (10.8%) were false-positive for IgG-anti-tTG. Sensitivity, specificity, PPV, NPV, and diagnostic accuracy of IgG-anti-tTG in celiac disease were 77.8, 89.1, 63.6, 94.2, and 87%, respectively. Human IgG-anti-tTG alone does not perform well as a diagnostic tool for celiac disease. The utility of anti-endomysial antibodies in a similar clinical setting needs to be evaluated.

Clinical Value of Immunoglobulin A Antitransglutaminase Assay in the Diagnosis of Celiac Disease

Our goal was to evaluate the possible correspondence between antitissue transglutaminase of immunoglobulin A class levels and stage of mucosal damage in patients affected by celiac disease. In addition, we assessed clinical use of antitissue transglutaminase values to predict biopsy results. One thousand eight hundred eighty-six consecutive patients with symptoms suggestive of celiac disease and 305 healthy controls underwent determination of serum levels of immunoglobulin A and antitissue transglutaminase. An intestinal biopsy was performed in subjects with antitissue transglutaminase levels > or = 4 IU/mL and in subjects with negative antitissue transglutaminase levels but with clinical suspicion of celiac disease. Histologic grading of celiac disease was consistent with the Marsh classification. One hundred eighty-six subjects with positive antitissue transglutaminase levels and 91 patients with negative antitissue transglutaminase levels were submitted to biopsy. In all healthy subjects, antitissue transglutaminase results were negative. Histologic evaluations in patients with positive antitissue transglutaminase levels gave the following results: type 0 in 25 patients, type 1 in 3 patients, type 2 in 4 patients, type 3a in 22 patients, type 3b in 74 patients, and type 3c in 58 patients. None of the patients with negative antitissue transglutaminase levels showed histologic findings suggestive of celiac disease. The mean antitissue transglutaminase values in patients without mucosal atrophy were significantly lower than in patients with mucosal atrophy. Antitissue transglutaminase values > or = 20 IU/mL were found in only 1 patient without mucosal atrophy. Our study found a strong correspondence between antitissue transglutaminase levels and stage of mucosal injury; antitissue transglutaminase values > 20 IU/mL seemed to be strongly predictive of mucosal atrophy.

Clinical Features of Celiac Disease in Indian Children

This study was designed to prospectively evaluate the clinical features of celiac disease (CD) in a large group of Indian children and to compare them with those from the West. Over a period of 5 years, a total of 549 children (< or = 14 years) with a clinical suspicion of CD were evaluated. Their detailed clinical features, investigations, and follow-up data were recorded. Complete hemogram, endoscopic duodenal biopsy, and celiac serology were done in all of the cases. Celiac disease was diagnosed on the basis of modified European Society of Paediatric Gastroenterology, Hepatology and Nutrition criteria. Celiac disease was diagnosed in 300 children; 39 were excluded because of lack of follow-up or poor response to gluten-free diet. The remaining 210 had normal villous architecture and served as controls. The mean (+/- standard deviation) age of children with CD was 6.7 +/- 3 years, and the mean duration of symptoms was 3.5 +/- 2.5 years. The majority (84%) presented with diarrhea; other features were failure to thrive in 91%, anemia in 84%, wasting in 87%, and stunting in 60% of cases. Among the serological tests, the best results were obtained with tissue transglutaminase. On follow-up (19.4 +/- 15.5 months), symptoms subsided in all cases of CD with a significant weight and height gain. Indian children with CD present late, with a significant delay in diagnosis. The majority presents with classic symptoms of diarrhea, failure to thrive, and anemia. There is a need for increasing awareness to pick up the atypical forms of the disease.